title: Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies.
abstract: BACKGROUND
  Recent studies have documented high rates of non-administration of ordered venous thromboembolism (VTE) prophylaxis doses. Intervention strategies that target all patients have been effective, but prohibitively resource-intensive. We aimed to identify efficient intervention strategies based on patterns of non-administration of ordered VTE prophylaxis.
  
  
  RESULTS
  In this retrospective review of electronic medication administration records, we included adult hospitalized patients who were ordered pharmacologic VTE prophylaxis with unfractionated heparin or enoxaparin over a seven-month period. The primary measure was the proportion of ordered doses of VTE prophylaxis not administered, assessed at the patient, floor, and floor type levels. Differences in non-administration rates between groups were assessed using generalized estimating equations. A total of 103,160 ordered VTE prophylaxis doses during 10,516 patient visits on twenty-nine patient floors were analyzed. Overall, 11.9% of ordered doses were not administered. Approximately 19% of patients missed at least one quarter and 8% of patients missed over one half of ordered doses. There was marked heterogeneity in non-administration rate at the floor level (range: 5-27%). Patients on medicine floors missed a significantly larger proportion (18%) of ordered doses compared to patients on other floor types (8%, Odds Ratio: 2.4, p<0.0001). However, more than half of patients received at least 86% of their ordered doses, even on the lowest performing floor. The 20% of patients who missed at least two ordered doses accounted for 80% of all missed doses.
  
  
  CONCLUSIONS
  A substantial proportion of ordered doses of VTE prophylaxis were not administered. The heterogeneity in non-administration rate between patients, floors, and floor types can be used to target interventions. The small proportion of patients that missed multiple ordered doses accounted for a large majority of non-administered doses. This recognition of the Pareto principle provides opportunity to efficiently target a relatively small group of patients for intervention.
authors.affiliation: Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, United States of America. kenneth@jhmi.edu
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Shermock
authors.forename: Brandyn D
authors.initials: BD
authors.lastname: Lau
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Hobson
authors.forename: Valerie S
authors.initials: VS
authors.lastname: Ganetsky
authors.forename: Peggy S
authors.initials: PS
authors.lastname: Kraus
authors.forename: Leigh E
authors.initials: LE
authors.lastname: Efird
authors.forename: Christoph U
authors.initials: CU
authors.lastname: Lehmann
authors.forename: Brian L
authors.initials: BL
authors.lastname: Pinto
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Ross
authors.forename: Michael B
authors.initials: MB
authors.lastname: Streiff
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage*; D003695:Delivery of Health Care / Q000706:statistics & numerical data; D004334:Drug Administration Schedule; D017984:Enoxaparin / Q000008:administration & dosage*; D006493:Heparin / Q000008:administration & dosage*; D006757:Hospital Units; D006801:Humans; D012189:Retrospective Studies; D016312:Treatment Refusal; D054556:Venous Thromboembolism / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D006493:Heparin